DHB in gun again for mental health services

SYSTEM BREAKDOWN: Hutt Valley District Health Board failed when it misdiagnosed Upper Hutt man Jerry Korewha in 2009, a coroner's report says.
SYSTEM BREAKDOWN: Hutt Valley District Health Board failed when it misdiagnosed Upper Hutt man Jerry Korewha in 2009, a coroner's report says.

A depressed Mongrel Mob member gave up his patch to turn his life around but died after the mental health system failed him.

Scathing remarks in a coroner's report issued yesterday say Hutt Valley District Health Board failed to complete a "simple" check, did not follow its own protocols and may have had a management-level breakdown when it misdiagnosed Upper Hutt man Jerry Korewha in 2009.

The board missed his recent history of chronic depression and put him through four alcohol and drug treatment sessions instead.

He had asked for more sessions days before he was struck by a car and died in March 2009.

Wellington coroner Ian Smith has now made at least six criticisms of the Wellington region's health boards in just over a year after suicides and deaths of the mentally ill.

Mental Health Foundation chief executive Judi Clements said yesterday that Mr Korewha's case amounted to neglect, and the mental health system needed to change.

"It's almost like people are on tramlines rather than being treated as whole people."

A DHB spokeswoman declined to comment yesterday but told the coroner looking into Mr Korewha's death that it had restructured its mental health services after he died. Mr Korewha had been suffering from chronic depression for at least 18 months when he was struck on State Highway 2 near Upper Hutt, after smoking marijuana.

His death was not found to be suicide, though the possibility existed.

Weeks earlier, he had travelled to Tauranga to hand his gang patch back and break his ties. He had also stopped drinking heavily.

He was well known to police and was under post-detention conditions for a drink-driving conviction when he died.

As part of those conditions, he was referred to the DHB to complete an alcohol and drug assessment, which should have led to appropriate treatment.

Mr Smith said a simple check of Mr Korewha's medical records from his general practitioner would have revealed a diagnosis of chronic depression from 2007.

"It is tragic that this man, having adopted a change in his life, should lose his life as he did."

Mr Smith's report includes scathing remarks by independent consultant psychiatrist Tom Flewett, who called the DHB's file on Mr Korewha "completely and utterly inadequate" and questioned its management and clinical governance.

The board restructured mental health services five months after Mr Korewha's death. It told the coroner that the changes would provide improved access to mental health and addiction services with specific emphasis on "low access" populations such as Maori, Pacific, children and youth.

It would also have a "no-barriers approach to access and follow-up, right service, right time and right place" and integration with the community.

On Monday, Mr Smith also criticised the availability of the district health board's respite facilities in 2008.

Depressed Lower Hutt man Jerome Perez committed suicide after waiting months for a respite placement.

The Dominion Post